Inspection on 26/03/07 for May Road (1)

This inspection was carried out on 26th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

May Road (1) 26/06/07

May Road (1) 30/06/06

May Road (1) 22/02/06

May Road (1) 08/03/05

May Road (1) 05/10/04

May Road (1) 08/03/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 May Road (1) 1 May Road Chingford London E4 8NB Lead Inspector Robert Sobotka Unannounced Inspection 26th March 2007 10:40 May Road (1) DS0000036520.V330558.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address May Road (1) DS0000036520.V330558.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. May Road (1) DS0000036520.V330558.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service May Road (1) Address 1 May Road Chingford London E4 8NB 020 8527 5258 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) London Borough of Waltham Forest Vacant Care Home 22 Category(ies) of Learning disability (19), Learning disability over registration, with number 65 years of age (3) of places May Road (1) DS0000036520.V330558.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th June 2006 Brief Description of the Service: The home is operated by The London Borough of Waltham Forest and is subject to the policies of the authority. It is a purpose built facility providing accommodation, care and support for 22 service users with learning disabilities. The home is arranged for unit living in four groups. The living areas are on two floors however there is no lift to access the first floor and therefore this floor would be inappropriate for anyone experiencing mobility difficulties. The home offers permanent, respite and intermittent care. It is situated in a residential location and is close to the town centre, providing easy access to all local amenities, leisure facilities and transport services. All service users occupy single rooms that are appropriately furnished and decorated. May Road (1) DS0000036520.V330558.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day and was unannounced. During the visit, the inspector spoke to those who live in 1 May Road and staff employed in the home. He also conducted a tour of the premises and checked various records. The aim of this unannounced inspection was to check the home’s progress towards full compliance with the Care Homes Regulations and the National Minimum Standards for Care Homes for Adults (18-65). At the end of this visit, a verbal feedback was provided to the Manager. The inspector would like to thank the staff and service users for contributing to this unannounced inspection. What the service does well: What has improved since the last inspection? Since the last inspection, the home has appointed the new home manager. It has been noted that some progress has been made to ensure that the quality of care offered to the service users is improved. The responsible person has ensured that the service user’s bathroom has been made operational. There has been an improvement in the way medication systems are handled. Supervisory staff have received training in providing professional supervision and staff now receive supervision as prescribed by the National Minimum Standards. The registered person has made arrangements to reimburse all service users living in May Road when their personal monies have been used to pay for staff meals, travel subsistence etc. Appropriate policies and procedures were now in place to guide staff in the appropriate handling of service users’ personal monies. Staff now received adequate induction that meets the criteria of the Sector Skills Council. May Road (1) DS0000036520.V330558.R01.S.doc Version 5.2 Page 6 What they could do better: There were 8 requirements, which have been repeated from the last inspection visit, these included: - The registered person must ensure that prospective service users needs are appropriately assessed before admission to the service. - The registered person must ensure all service users have a care plan that reflect their needs and aspirations. - The registered person must ensure the service undertakes comprehensive risk assessments for service users. - The registered person must ensure the Commission is notified of all significant events that may affect the wellbeing of service users. - The registered person must ensure service users have a health care plans in place that reflect their individual health needs. - The registered person to ensure that no person works in the home unless a satisfactory CRB disclosure has been obtained by the Local Authority. - The registered person must ensure that a named person is registered with the Commission as manager of the service. - The registered person must ensure that the home’s fire safety checks are undertaken as prescribed. In addition, the following 11 requirements were made following this inspection visit: - It is required that an assessment is carried out in relation to the service user who may require nursing care to establish the most appropriate placement for that person. - The responsible person must ensure that the home’s statement of purpose is amended to include the details of the new manager and to reflect any changes to the staffing level. - It is required that all perishable food is labelled once opened to prevent food poisoning. - The responsible person must ensure that all confidential files are kept locked when not in use. May Road (1) DS0000036520.V330558.R01.S.doc Version 5.2 Page 7 - An application for minor variation must be submitted to the Commission to seek approval for the home to continue to provide care and accommodation to any service user over the age of 65 years. - The responsible person must ensure that a wheelchair weighing scales are purchased for the home. - The responsible person must ensure that monitoring charts in relation to each service user’s health and personal care offered are completed when required. - The responsible person must ensure that visits from the registered provider must be undertaken on a monthly basis and shall supply a copy of the report to the home and the Commission. - The responsible person must ensure that the fire risk assessment in drawn up as required by the London Fire and Emergency Planning Authority - The responsible person must ensure that the requirements from the home’s electrical wiring inspection carried out on 08/07/02 are carried out. Copy of the satisfactory test must also be submitted to the Commission. - The responsible person must ensure that the main kitchen is adequately ventilated at all times. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. May Road (1) DS0000036520.V330558.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection May Road (1) DS0000036520.V330558.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The homes statement of purpose required minor amendments. The home’s admission systems required improvement to ensure that a current and full assessment of need is undertaken to establish its ability to meet the needs of the service users admitted to the home. It is also required that an assessment is carried out in relation to the service user who may require nursing care to establish the most appropriate placement for that person. EVIDENCE: The home’s statements of purpose required minor amendment, as the document viewed at the time of this inspection the document included details of the previous home manager. The responsible person must ensure that the home’s statement of purpose is amended to include the details of the new manager and to reflect any changes to the staffing level. There have been two new admissions to the home since the last inspection. One of the files viewed checked during this visit showed that the service user had a clinical diagnosis of dementia, which was known to the home prior to the person moving in there. As the home is not registered to provide care and support to those with dementia, this meant that the service user was admitted to the home inappropriately. This matter was brought to the attention of the home manager. The home manager stated that she was in the process of designing pre-admission assessment. The requirement in relation to the May Road (1) DS0000036520.V330558.R01.S.doc Version 5.2 Page 10 home’s admission systems remains unmet and must be met without any further delay. As part of this visit, the inspector had a discussion with several members of staff, some of who felt that of the needs of one of the service users have increased and that that person required nursing care. It is therefore required that an assessment is carried out in relation to the service user who may require nursing care to establish the most appropriate placement for that person. In addition, some of the service users have reached the age of 65 and an application for minor variation must be submitted to the Commission to seek approval for the home to continue to provide care and accommodation to any service user over the age of 65 years. May Road (1) DS0000036520.V330558.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9, 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Limited progress has been made to ensure that the previous requirements in relation to the care planning and risk management have been met. Improvements are required to ensure that service users are enabled to make decisions about their lives. This may place service users at risk. This potentially leaves people who use the service at risk. Confidentiality required improvement. EVIDENCE: During this inspection visit, the inspector viewed care plans of 4 service users. Limited progress has been made to ensure that the care plans are reviewed and kept-up-to date. One of the care plans viewed, who belonged to the service user with dementia was drawn up in December 2005 and was very basic. In addition, the document did not address the service user’s domestic skills. Another service user’s care plan did not reflect some of the points agreed during their placement review. The third care plan checked by the inspector has not been reviewed since June 2005. It was noted however that one of the care plans viewed was well written, comprehensive and up-to-date. May Road (1) DS0000036520.V330558.R01.S.doc Version 5.2 Page 12 As some of the service users’ care plans have not been reviewed for quite sometime, the inspector was unable to fully assess whether the home enabled service users to make decisions about their lives with assistance when needed. During a placement reviewed for one of the service users “case-tracked” during this inspection, it was agreed that a communication passport should be arranged, however this was not reflected in their care plan and there was no evidence that the communication passport was put in place. Although there was some evidence that service users are supported to make decisions about their lives, further work is required to evidence that this standard is fully met. Some of the risk assessments viewed were not up-to-date and required review/updating. In case of one of the service user, their care plan has not been reviewed since May 2005. The requirement in relation to the care plans has therefore been repeated and must be met without any further delay. Confidentiality required improvement, as during the tour of the premises, the inspector found some of the service users’ files left in of the lounges, which could be accessed by anyone visiting the home. The home manager stated that they must have been left by a member of staff who was completing daily logs on that shift. The responsible person must ensure that all confidential files are kept locked when not in use. May Road (1) DS0000036520.V330558.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Those who live in the home were encouraged to lead active lifestyles within local community and develop and maintain friendships and family links. Service users enjoyed food offered by the home, however storage of food required improvement. EVIDENCE: Following the discussion with the service users and staff, the review of documentation and both direct and indirect observation, the inspector was satisfied that service users living in the home were encouraged and supported to leave active lifestyles and to be part of the local community. Service users are offered a good range of culturally appropriate activities both indoors and outdoors. Some of the service users access local day centres. Service users are also encouraged to maintain appropriate relationships with their families and friends. There was evidence that service users visit their families and vice versa and that in some cases relatives are involved in the May Road (1) DS0000036520.V330558.R01.S.doc Version 5.2 Page 14 care planning process for the service users accommodated in the home. Visitor’s book was in place and was being maintained. As part of the visit, the inspector viewed kitchen premises. They were generally kept clean, however the appeared to be poor ventilation, as the kitchen was very hot and smoky. The responsible person must ensure that the kitchen premises are adequately ventilated at all times. Some of the products were not labelled when opened. The inspector found some tomato ketchup and salad cream bottles, which were opened but not labelled. It is therefore required that all perishable food is labelled once opened to prevent food poisoning. At the time of this inspection, the home was using an agency chef, however the home manager informed the inspector that the home was in the process of recruiting a permanent chef. Menus were in place, which evidenced a choice of mealtimes. Pictorial menus were also in place. Service users spoken to said that they enjoyed food offered in the home. May Road (1) DS0000036520.V330558.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Some improvements have been made to ensure that appropriate personal care and support is offered to all service users living in the home, however further work is required to ensure that the above standards are fully met. EVIDENCE: It was discovered at the last inspection visit, that following a refurbishment of one of the bathrooms, three service users had to visit another local authority service to have a bath. At the time of this visit, the inspector was informed that this situation has now been rectified. The inspector felt that due to the increasing level of physical needs of some of the service users, an occupational therapy assessment was required to assess the current bathing needs of some of the service users and the home’s environment. Very limited progress has been made in relation to the health care plans. Documents viewed during this inspection visit were not signed/dated; one person’s health care plan did not fully address this person’s needs. Another person’s plan included a template format, which was not personalised and only included the service user’s name. There was no evidence that this document has been reviewed since February 2006. May Road (1) DS0000036520.V330558.R01.S.doc Version 5.2 Page 16 The inspector was concerned to find out that some of the checks agreed in service user’s care plans were not carried out, this included maintaining weight chart, even though there were concerns about the service user’s weight. It was also noted that some of the service users were not weighed, but a measurement of their waist was taken instead. The inspector was informed that this was done, as the home did not have a wheelchair weighing scales for the service users who used wheelchairs or were unable to bare weight. This practice is unacceptable and must be stopped. The responsible person must ensure that a chair weighing scales are purchased for the home. Some of the health monitoring records were not completed on a regular basis and did not give an accurate picture in relation to the service users physical and healthcare needs. For example, a bowel movement sheet for one of the service users indicated that they have opened their bowels 4 times in January, twice in February, and twice in March. Some of the personal care charts were not completed on regular basis and in some cases were not completed correctly, i.e. a member of staff have ticked the form on several occasions to indicate she had shaved a female service user, even though there was no indication that this was required, and this was subsequently confirmed by staff in the home at the time of the inspection. The responsible person must ensure that monitoring charts in relation to each service user’s health and personal care offered are completed when required. As previously mentioned, some members of staff felt that one service user now required nursing needs and the home was no longer able to appropriately meet their needs. Medication stocks were checked and they were found correct. All staff have recently received medication training. There no gaps noted on medication administration sheets. Appropriate records in relation to medication received by the home and disposed of were found maintained. The home had a medication policy in place. May Road (1) DS0000036520.V330558.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service responds to complaints within its timescales, however the Commission is not always informed of all significant events that may affect the wellbeing of service users. EVIDENCE: There have been three complaints made to the home since the last inspection, all of which were appropriately dealt with. One of the service users spoken to stated that he would raise any concerns with the manager or a member of staff on duty. Staff have recently received training in adult protection and their responsibilities in responding to suspected or actual abuse. During this inspection visit, the inspector checked finances of two of the service users. Money kept in the home matched the recorded balance on the cash record sheet in both cases. The requirements in relation to the way staff handle service users money have now been met. During the inspection the inspector spoke to the Service Manager, who confirmed that all service users have been reimbursed for when their personal money had been used to pay for staff meals, travel subsistence etc. The inspector viewed record of accidents and incidents. The requirement that the Commission is informed on notified of all significant events that may affect May Road (1) DS0000036520.V330558.R01.S.doc Version 5.2 Page 18 the wellbeing of service users remains unmet and must be met without any further delay. May Road (1) DS0000036520.V330558.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 29, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The premises are generally well maintained, however some parts of required refurbishment and/or improvement. An occupational therapy assessment is also required to assess the home’s bathrooms in relation to the service users’ needs. EVIDENCE: The home is situated close to local amenities and shops. The premises are divided into 4 units. Each unit is self-contained with its own lounge and dining room. Service users are offered a key to their bedrooms, although not all choose to use it. The inspector viewed some of the bedrooms, which were generally clean and hygienic and contained appropriate furniture and fittings. In one of the service users’ bedrooms the inspector noted that one of his cupboards was broken and required replacement/repair. In addition, in the same service user’s bedroom wardrobes and a chest of drawers unit was labelled with stickers, which were placed to direct staff when putting things away in the service user’s room. As May Road (1) DS0000036520.V330558.R01.S.doc Version 5.2 Page 20 this was unsightly and did not serve any purpose, the inspector advised the manager to remove the labels. This was done immediately. As previously mentioned the kitchen premises were not adequately ventilated. The responsible person must ensure that the kitchen premises are adequately ventilated at all times. In addition an occupational therapy assessment was required to assess the current bathing needs of some of the service users and the home’s environment. The home manager informed the inspector that she had submitted the request to her manager for some of the bathrooms to be redecorated. She also said that she was reviewing the home’s security arrangements and has recently installed a security door code on the entry door and there were plans to install the date for the home’s car park. The premises were found to be clean and hygienic at the time of this unannounced inspection. Appropriate laundry facilities and clinical waste disposal arrangements were in place. May Road (1) DS0000036520.V330558.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although limited progress has been made to improve the home’s recruitment procedures, further work is required to ensure that service users are supported and protected by the home’s recruitment policy and practices. EVIDENCE: The home manager informed the inspector that whilst there were no staff vacancies, however the home was using some agency staff to cover sickness and annual leave taken by permanent staff. The inspector viewed the duty rosters, which showed that there were appropriate staffing levels on duty. At the time of this inspection, the home employed 12 residential support workers and three deputy managers. In addition, there were 2 members of staff who worked during nights. The home operates a waking night and sleep-over system, where one member of staff is awake during the night and two members do sleep-overs and can be summoned in case of emergencies. Staff spoken to felt that the current staffing levels were sufficient. The home manager informed the inspector that the staffing levels were recently reviewed May Road (1) DS0000036520.V330558.R01.S.doc Version 5.2 Page 22 and it has been decided that there should be 3 Deputy Managers in place as opposed to 4 and instead extra resources should be allocated to do activities. The home manager works mainly between Mondays and Fridays (office hours) and deputy managers work various shifts. Staff now receive adequate induction training that meets the criteria of the Sector Skills Council. As part of the visit, the inspector checked staff personnel files. Not all files viewed contained Criminal Records Disclosures. The home manager informed the inspector that not all CRB disclosures were made available to her. In addition some of the CRB checks were old and did not include checks against the Protection of Vulnerable Adults Register. The inspector was also told that some of the permanent staff used to work as agency staff in the home and were subsequently appointed as permanent staff. New Criminal Records Bureau Disclosures should have been obtained in respect of those carers. The requirement relating to the home’s recruitment practices remains unmet and has therefore been repeated and must be met without any further delay. Further non-compliance may result in the Commission considering an enforcement action against the provider. A random sample of supervision records was checked during this visit and it demonstrated that staff received regular supervision sessions. Regular team meetings were also taking place, minutes from which were available for inspection. May Road (1) DS0000036520.V330558.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 42. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Further work is required to ensure that all aspects of the home are appropriately managed and that all National Minimum Standards are met. EVIDENCE: The home has got a new manager in place, which commenced work in the home in August 2007. Throughout the inspection the inspector received positive comments from both staff and service users in relation to the manager’s skills and conduct. The new manager has for a National Vocational Qualification Level 4 in Management; she also holds a nursing qualification and is currently in the process of obtaining NVQ Level 4 Registered Managers Award. The service has not had a registered manager in post for over two years and at the time of this visit; the application for the manager to become registered has May Road (1) DS0000036520.V330558.R01.S.doc Version 5.2 Page 24 not yet been submitted to the Commission. This must be done without any further delay. The inspector checked record of visits from the responsible person, which must be carried out in accordance with the Regulation 26 of the Care Homes Regulations. Although reports from some of the visits were available in the home, there was no evidence that these visits were carried out on a monthly basis. The responsible person must ensure that visits from the registered provider must be undertaken on a monthly basis and shall supply a copy of the report to the home and the Commission. As previously mentioned, not all records required by law were maintained and/or kept up-to-date. This included: - Care plans, - Risk assessments, - Health monitoring records, - Staff personnel files, - Regulation 26 reports, - Health and safety records. This must be remedied without any further delay. The inspector checked a number of health and safety files. The home received a visit from the London Fire and Emergency Planning Authority on 14/03/07 and following the visit it was required to draw up the fire risk assessment. This must be drawn up without any further delay. In addition, there was no evidence that the home’s fire alarm was tested in the 1st week of March. The home’s emergency lighting system has not been tested since 13/12/06. The requirement from the last inspection that the registered person must ensure that the home’s fire safety checks are undertaken as prescribed remains unmet and must be met without any further delay. Last fire drill was carried out on 27/02/07. The home’s electrical wiring was last inspected on 08/07/02 and one of the sheets indicated that improvements were required. The actual sheet with the required improvements was missing and there was no evidence that the problem has been rectified. The responsible person must ensure that the requirements from the home’s electrical wiring inspection carried out on 08/07/02 are carried out. Copy of the satisfactory test must also be submitted to the Commission. As previously mentioned, it is required that all perishable food is labelled once opened to prevent food poisoning. The Landlord’s Gas Safety Certificate was issued on 18/07/06 and was satisfactory. The home was appropriately insured for its purpose. May Road (1) DS0000036520.V330558.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 3 1 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 2 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 x 2 2 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 1 3 x 2 x 2 2 x 1 x May Road (1) DS0000036520.V330558.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14 Requirement The registered person must ensure that prospective service users needs are appropriately assessed before admission to the service. (Previous timescale of 25/03/07 was not met.) The registered person must ensure all service users have a care plan that reflect their needs and aspirations. (Previous timescale of 25/03/07 was not met.) The registered person must ensure the service undertakes comprehensive risk assessments for service users. (Previous timescale of 25/03/07 was not met.) The registered person must ensure the Commission is notified of all significant events that may affect the wellbeing of service users. (Previous timescale of 25/03/07 was not met.) The registered person must ensure service users have a health care plans in place that reflect their individual health needs. (Previous timescale of DS0000036520.V330558.R01.S.doc Timescale for action 01/06/07 2. YA6 15 15/05/07 3. YA9 12 15/05/07 4. YA23 37 01/05/07 5. YA19 15 15/05/07 May Road (1) Version 5.2 Page 27 25/03/07 was not met.) 6. YA42 23 The registered person must ensure that the home’s fire safety checks are undertaken as prescribed. (Previous timescale of 25/03/07 was not met.) The registered person to ensure that no person works in the home unless a satisfactory CRB disclosure has been obtained by the Local Authority. (Previous timescale of 25/03/07 was not met.) The registered person must ensure that a named person is registered with the Commission as manager of the service. (Previous timescale of 25/03/07 was not met.) It is required that an assessment is carried out in relation to the service user who may require nursing care to establish the most appropriate placement for that person. The responsible person must ensure that the home’s statement of purpose is amended to include the details of the new manager and to reflect any changes to the staffing level. It is required that all perishable food is labelled once opened to prevent food poisoning. The responsible person must ensure that all confidential files are kept locked when not in use. An application for minor variation must be submitted to the Commission to seek approval for the home to continue to provide care and accommodation to any service user over the age of 65 years. The responsible person must ensure that a wheelchair weighing scales are purchased DS0000036520.V330558.R01.S.doc 15/05/07 7. YA34 19 15/05/07 8. YA37 9 01/05/07 9. YA3 14(2) 01/06/07 10. YA1 4(1)(c), 6 15/05/07 11. 12. 13. YA17 YA10 YA3 16(2)(g), (h) 17(1)(b) Care Standards Act 2000 01/05/07 01/05/07 15/05/07 14. YA19 16(2)(c) 15/05/07 May Road (1) Version 5.2 Page 28 for the home. 15. YA19 17(1)(a) Sch 3 The responsible person must ensure that monitoring charts in relation to each service user’s health and personal care offered are completed when required. The responsible person must ensure that visits from the registered provider must be undertaken on a monthly basis and shall supply a copy of the report to the home and the Commission. The responsible person must ensure that the fire risk assessment in drawn up as required by the London Fire and Emergency Planning Authority. The responsible person must ensure that the requirements from the home’s electrical wiring inspection carried out on 08/07/02 are carried out. Copy of the satisfactory test must also be submitted to the Commission. The responsible person must ensure that the main kitchen is adequately ventilated at all times. 15/05/07 16. YA39 26 01/06/07 17. YA42 23(4) 01/05/07 18. YA42 23(2) 15/05/07 19. YA24 23(2)(p) 15/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations May Road (1) DS0000036520.V330558.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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